 Welcome. This is Craig Thomas, your host on Much More on Medicine, and it's part of the Think Tech Hawaii live stream series. Today my guest is Mark Leggett from Hawaii Life Flight. He's a regional director and charge of the medical operations. Welcome, Mark. Thanks for having us on. You're welcome. It's my pleasure that you're here, and you're here because the theme, as I know you know, has been medical care in an island state. And it's always a challenge with a mix of urban and rural, but if you add ocean, it gets much more challenging. And so over the past few weeks we've been talking about how do you organize where the patient goes and should they go and also what should be done before they go. We've also talked about some special conditions. Co-host Tom Forney had the stroke team on, and that's a good example of something that has a time-dependent need for specialty services. Some patients qualify for Tharmvector B, for example. It can only be done in a couple places in the entire state. And truthfully, should only be done in a couple places in the entire state because there are not that many patients who qualify. You've got to have enough to be good at it. And as we know, there are other conditions. Trauma comes to mind, cardiac events come to mind. So the basic premise is if there is a patient who could benefit from a life or limb saving procedure at a tertiary center, then we need to do the right things to package them up and get them there. And the key move is we need you. So I was hoping you would kind of give us a little background on sort of the history and then current status of inter-island air transport. And having been, thank God, never a patient, but have summoned you many times, I've been impressed. And I've also watched Devol over the years. So thanks for joining us. I look forward to painting a picture of this key link in healthcare in Hawaii that most people probably haven't thought about. Right. And as we say, we're here to help out. We hope you don't have to utilize us, but we are here if you are need us. And what most people don't realize is behind the scenes, there's quite a bit of a infrastructure in place. As you alluded to, it's developed more and more over the past three decades. Essentially, there was a long-standing air ambulance service for about 20, 25 years that did a good job in the state. And then early in the millennium, we had a change with, I think, an improvement in the air medical services around 2006, adding more assets in the state. Originally, we had maybe two to three assets throughout all the Hawaiian islands. And folks here would have to wait a whole day or days potentially to get from a neighbor island to a higher level of care. And then as we went into the millennium, we've seen that gradually improve. And now we have anywhere from nine to 12 air medical assets available throughout the islands working in orchestration with the trauma system, the hospital system, Queens Medical Center, Kapiolani, and then all the other major hospitals. So it's still something that we want to improve upon. Our mission is to provide safe, efficient, compassionate air medical transport. We do want to do the right asset and the right amount of time to the right place. And it's still a work in progress, but we think we've come a long way, obviously, in the last decade even. I think that's absolutely true. And it's sort of occurred in parallel with changes in medicine. Honestly, when I started as an emergency doctor, if somebody came in in the middle of the night, we did the CAT scan the next morning. Well, now that same patient would get a CAT scan, might get a CT angiogram, would get thrombolytic therapy at any community hospital across the state. And if the angiogram was appropriate, and after teleconsultation with the stroke center, they might well use your services to get there for a thrombectomy. So as medicine has evolved, the need for change in your services evolved. And I could say the same thing about trauma. There's now a statewide trauma system, which again, based on the capabilities of the various hospitals, and the littlest ones don't even have a surgeon. And the larger ones have tremendous surgical capability and will do much more initially. But in the end, they may need, say, neurosurgery or some other subspecialty surgery that's not available except at a tertiary center. And cardiac, same way. When I started, nobody got stented, cabbages were done, but mostly weekday days. And now, of course, it's a 24-7 sort of stepped kind of care just like these other things. Do the right thing initially, get the right consultation. And if necessary, it sometimes is, send them. And so the basic parameters requiring transfer are a diagnostic impression at the the initial center, appropriate stabilization within the capacity of the initial facility, a communication with the tertiary center agreement that there's actually a service that would benefit the patient at the tertiary center. Obviously, if there's no nothing more to do, there's no indication for transfer. And then working with the aeromedical system for transfer. Now, listening to you, I was struck by how we all have our jargon. Would you describe assets for people? I know what you're talking about. They'll be interested. And we should call airplanes and helicopters what they are. Yeah, absolutely. It's really interesting, folks. And I've seen in some of the other series that we've talked about different aspects of our EMS system in the state with ground. Ambulances. When we refer to assets, we are referring to air ambulances, essentially. Of course. Aircraft. And when we talk about having limited assets or limited aircraft years ago and now having, it's not unlimited, but they are strategically placed based on where we see the most need to transport patients from the neighbor islands into, usually into Oahu. What we're talking about are fixed wing aircraft. And we have, you know, with our company, and there's two companies operating the state right now, there's a combined number of fixed wing aircraft that are usually in service around nine aircraft. And there's one rudder wing helicopter. I was about to say, road or wing. Not everyone knows rudder wing. But we'll say helicopter. It's in a unique situation based in Kona, due to some of the distance from that hospital to the airport. But what's interesting for folks to understand is the way this works, like you said, is a continuum of care, you know, from a time that the patient arrives at outer neighbor island hospital emergency room. And they are, you know, assessed, you know, diagnostic studies done. And then if they're determined that it's time critical, or they need to get for a high level of care that's not available at that facility, then the activation, you know, begins, those sending or receiving hospitals determine they're ready to, you know, send them and accept that patient. And then they contact us, the air medical provider. You know, we have behind the scenes a 24 seven communication center that's here locally on Honolulu with local communication specialists that have lived here their whole lives and understand the islands. It's much more challenging than some rural aspects in the mainland. As we all say, once we've come to Hawaii, Hawaii is completely different. And it truly is, even in the terms of air medical transport, for sure. But it starts with a call usually by, you know, the Queens Transfer Center to Queens patient, which the majority of them are. But it also could involve, you know, other other players to other similar call centers that have started. And once activated, our communication specialists will work as a team and activate. We have 24 seven, you know, experienced pilots at six bases throughout the state, Lee who a Honolulu Molokai, and then three on the big island, Kona, Hilo, and Kamuela Airport, which is why may on the big island, they will activate that pilot. And also activate a 24 seven critical care air medical crew, which consists of critical care nurse and critical care paramedic to have special board certifications beyond the realm of ground transport and similar really to hospital critical care. Once they're activated, those teams are all locally based. And so for the most part, they'll head in with all their critical care, monitoring and medications. And they'll get the patient package for transport at the local hospital. In most cases, they're into the hospital within 30 minutes. Our dispatch center works hand in hand with the local ground ambulance providers, depending on which island we're flying from. So it would be AMR for Oahu, Maui County and Kauai County. And also on the big island, but also we do work with the Hawaii County fire in some cases to help, you know, come in and respond. What we have to do then is get the patient to the fixed wing aircraft via ground ambulance. So there's a bunch of moving parts there. Again, everyone works as a team and our communication center coordinates that. And then there's a flight over to Honolulu or some cases Maui, if we're going to some care over there, but usually over to Honolulu. And then we work with the ground providers to take our crew and patient into the receiving facility. The difference with the helicopter in Kona is it can pick the patient up at Kona Hospital and fly him directly from that helipad into Honolulu and land them on the helipads here in Honolulu. It's usually Queens that we go to. It saves, as we know, some of those long delays with ground traffic that you'd encounter on two-lane roads on Kona or sometimes in Russia on the H1. In some cases, the quickest activation to arrival at bedside in Honolulu with the helicopter has been, you know, two to two and a half hours versus three and a half hours total with the fixed wing or sometimes even four hours. But general transport time from activation from all of our neighbor islands to get them to Honolulu is around two and a half to three hours with the exception of, you know, longer traffic situations. And again, I think that's a great improvement over what it was and what you recall it being, you know, even 10 years ago and definitely 15 years ago. It's been a huge change. And as I said, the demands in medicine have sort of upped the ante in the timeliness. So we're really appreciative. I will tell you from the point of view of an ER doc, we are always delighted when your crew comes in and we get the patient packaged, they disappear, and then we hear later, they got there. So thank you. So this is Craig Thomas. We're going to take a break. It's much more on medicine with guest Mark Leggett and assisted by engineers Ray and Rich. Thank you. This is Think Tech Hawaii, raising public awareness. I'm DeSoto Brown, the co-host of Human Humane Architecture, which is seen on Think Tech Hawaii every other Tuesday at 4 p.m. And with the show's host, Martin Desbang, we discuss architecture here in the Hawaiian Islands and how it not only affects the way we live, but other aspects of our life, not only here in Hawaii, but internationally as well. So join us for Human Humane Architecture every other Tuesday at 4 p.m. on Think Tech Hawaii. Welcome back. This is Craig Thomas with Much More on Medicine. My guest today is Mark Leggett, who is teaching us about the challenges of aeromedical transport in an island state. So I think, Mark, you've painted a kind of nice picture of what's involved. Maybe we could talk a little bit about how many patients probably get transferred in a year, sort of the breakdown of the major categories of patients. That kind of thing. And then we're going to kind of move into special circumstances, which are always interesting. Sure. Yeah. So as we talked before, the system structure involves six, at least for our company, six aircraft bases throughout the state. And in general, they will average at least a flight a day from outer island. They were all in bringing them into tertiary care. But there are some days that are busier than others. And between all the air medical, fixed wing, air ambulances in the state, we're all flying. So in a year, the flights are in the thousands. There's an episode, I think, earlier where we talked about the Queen's Transfer Center. And they definitely have a really good pulse, because they do the majority of the flights. And it was mentioned that we're talking on the order of 3,500 air medical transports, getting patients to higher level care. And that's fairly accurate. That's a combined number between the two air medical providers in the state. So one way of thinking that is nearly 10 a day. And that's impressive. And that's generally my sense. I work at some small sites. And even little hospitals, one or two a day. And bigger ones, often more. So it's a huge part of the healthcare network, shall we say, the tiered approach to healthcare across the state. Yeah. And I think that over, as we spoke again, our general mission, whether it's on the ground or in the air, in the hospitals, is to do safe and compassionate and efficient care. And safety's first in our compassion, patient care part. But the efficiency part's huge. And I think, as we look at limited number of resources, there's the cost that go into it, obviously, on both sides, that we want to be as efficient as possible. And transport patients, really only when they need to be. And so those numbers that we're talking about have probably gotten more and more efficient or continuing to as the system evolves and works with the Outer Islands to provide additional care that's needed on the Outer Islands. But we still, between the local residents and the tourists that visit our state, accidents happen, heart attacks happen, these emergencies happen. And we have to get them to Honolulu for the most part. Yes. And so the nice thing is that there are, there's more sort of care standardization and long distance support than there used to be. Because my belief is that the best care is when possible, provided closest to home. So if you can treat someone possibly with a telemedical consult, which we do at several of our sites on Island, that's great. Patient doesn't need to be transferred. The family is nearby. They're home when they get discharged. That's fabulous. But there are other patients need some stuff done right away, need to get somewhere for the neurosurgeon or the interventional cardiologist or the interventional radiologist in case of strokes. So there are lots of reasons that you want to take special categories of patients to a tertiary center. And I think the basic principle is there needs to be a procedure or service that they are likely to benefit from. Not guaranteed. There are no guarantees in medicine, but are likely to benefit from and it's available at a different Island. And so that's why this occurs. And it's getting more and more coordinated. I'm really pleased about it. Yeah. Yeah. And we, you know, we definitely have tried to be, you know, besides providing that service and be as efficient as we can with that, we've tried to be, you know, sensitive to working as a team player in the system with all the providers, the sending, receiving facilities, networks, the ground providers. And, you know, we do, like you said, we, it's about results and sending the right patient that needs those services. I think we're getting better as a system doing that. But we definitely want to be here when the system needs us to, to fly them. So I'm kind of laughing inside because you are touching on how many parts there are to this. And I just, everybody should know it's, it's a dance. And for example, each Island has a little bit different ground situation in terms of the ground amulets and the transfers. And each facility has a little different nuance. So thanks for the dance. There also, of course, are special cases. Your aircraft are not particularly large. And there are some patients just to put it bluntly, won't fit. And we're talking about physically won't fit. And there's a protocol for measuring, I know. There's a lot of discussion that occurs at those times. And in the end, there's a backup plan as there should be. And it's the Coast Guard. You want to describe the C-130 situation a little bit? Sure. I can back up just a little bit and just talk about our, our capabilities and limitations and how it then flows into needing, needing additional help sometimes with bariatric or, you know, larger patients. For our fixed wing aircraft, the majority of those aircraft have capability to fly most patients. We're limited by weight and balance of the aircraft, the fuel, all the passengers and equipment on board. So that's a hard and fast role just in aviation and safety. But it's, it's not a set weight per se, but we, we generally look at, you know, patients that are over, you know, 375 pounds to 400 pounds give or take, but also their girth or their width. Most of the fixed wing aircraft here, really all the fixed wing aircraft in the state, the maximum width is 26 inches going in and out of the door and loading. For our red wing aircraft, it, it's going to vary, you know, with weather and with crew size, typically in patient size also, it's a little bit less on that aircraft and that particular aircraft, it will be able to do most of the flights, but if it cannot, then we have fixed wing assets. And, you know, when we take patients, we try to take at least one family member most of the time, if they can come with us because that's for, you know, continuity of care and the family is part of the patient. They are patient too. And part of those challenges we talked about in this state, you know, when you do have to displace someone off their home island to their other, other facility, especially when they're really sick, it's really hard on the family. You'd want them all to be there and at least have one family member. That's important. But if that's an issue with weight and balance, then we won't even take the family member. So flowing into what happens when they're, you know, beyond our capacity to take them, we do have to involve the sending and receiving facility, our medical direction, which we have 24-7 physicians on call that help our crews. Our, you know, managerial, upper operational logistic support helps make the decision. And we also work with the district medical directors and the state EMS system on each island. And that's where you talk about that Coast Guard case. When you're doing that, we all go through the procedure and approvals at the local level, but then ultimately it goes up to the federal government, to the Coast Guard and the decisions made in Washington. It's a major, it's a major button to push and you're laughing because you've, we've had to, we've all worked with pushing that button so to speak, but they usually work with us and if it's life or limb threatening. Chops to them, they do a great job. It does take a while. So that's right. And it sort of points out both the interdependence and the resourcefulness that and something you're not involved in, but since our group provides some remote medical control over some of the outlying islands and specifically Palmyra, 900,000 miles to the south and Curay about 1100 miles to the northwest is that at the end of the chain, there are long range transports, coast guards involved, sometimes private carriers. And you just think the inner island Coast Guard activation is a challenge. Those ones take days, but it's part of life in an island state. The other thing we've talked about, who should stay, who should go, something we're working with, with the emergency medical services advisor committee, they have an aeromedical subcommittee, is we're looking at some special categories of who should stay and who should go because there are some patients, honestly, who should stay. And these are patients who are unlikely to benefit from services at a tertiary facility or for whom the risk of transfer, given their condition, is greater than the likely benefit from their arrival at the facility. And I'm kind of interested in your thoughts of that situation. It's early days, we're working on some guidelines for that. Yeah, absolutely. So yeah, we've had the privilege to participate with the Aeromedical Committee with our EMS advisory council, and just a really good discussion with all the players in the state, which is the ground, the medical direction on each island and the air medical providers. As we alluded to before, the patients that we are taking that generally benefit are going to be time sensitive, cardiovascular, cardiac catheterization type cases, neurosurgical type cases, severe trauma, and sometimes some critical medical ICU type patients for which the air medical provider does have that capability to provide continuity of care. But when we get to the sickest of the sick patients, that's when this question has come up. Even though we can provide that continuous care, it is a little bit more, and I probably understate it, it's a little bit more challenging as we take them through ground and air transport, moving them around. We have the capability to provide all that care, but it gets more challenging. So at that point, we leave it in the hands of the sending and receiving physicians and call centers to really weigh and balance that out. We definitely will be responsive to that, but we'll also involve our medical direction too in that discussion if we think it's a case that's borderline. Exactly. I think that's a completely fair summary, and we're working on some guidelines that would apply statewide to help correct these, because in the heat of the moment, it's easy to lose track of what's the benefit, what's the harm, and you have to keep track of that. Sometimes the harm, namely, removed from a setting with a lot of resource to a small aircraft and then into an ambulance and then back to another thing. The harm is greater than the benefit, so it's something we need to be addressing. I think we're sensitive to it. We'll emphasize that we're definitely there to do those transports and have the capability, but I think it's really good from the standpoint again to the safe, compassionate, efficient mission we have. That's part of all three of those variables. I mean, all three of those are emphasized pretty heavily in this discussion, so we want to do what's right and do no harm overall for the patient, so that's what we're looking at. Right care, right place, and I'd like to thank you for facilitating that happening and shining a light on a piece of the medical continuum, shall we say. We talked about pre-hospital with Jim Howe from emergency medical services. We are looking at now how patients get from smaller hospitals to larger ones and appreciate your help over the years and look forward to this in the future. Again, this is Craig Thomas, your host on Much More on Medicine, and my guest is Mark Leggett, who directs the Hawaii Light Flight Services here in Hawaii.